EnCase EAP Affiliate Partner Request Form

First Name

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Last Name

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Practice / Organization Name

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Primary Location / Address

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Additional Service Locations (If Applicable)

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Type of Services Offered

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Adults

Adolescents

Children

Anxiety

ADHD

Trauma

Stress Management

Substance Use

Other (please specify)

If Other, specify here:

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Please upload a copy of your Current Resume and a Copy of State License and/or Certifications

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